JUST BECAUSE YOU BUILD IT DOESN’T MEAN THEY’LL COME: TAKE HOME MESSAGES FROM IAS

Participants at last month’s International AIDS Society Conference in Rome were energized by positive findings on new biomedical HIV prevention interventions. Thirty years of dedicated work have resulted in the HPTN052 trial’s promise of HIV treatment as prevention and in positive findings from two clinical trials on pre-exposure prophylaxis, while voluntary medical male circumcision continues to gain ground worldwide. These scientific breakthroughs open up exciting new opportunities for HIV prevention.

Yet, amid these game-changing developments, plenary remarks by Dr. Susan Kippax, emeritus professor in the Social Policy Research Centre at the University of New South Wales, added a critical perspective about the challenges that lie ahead. Among a handful of others at the conference, Kippax reminded us that moving from HIV prevention efficacy (what works in research) to effectiveness (what works in practice) requires behavioral and programmatic research capable of translating “proof of concept” into real change on the ground. This is a theme she has been developing for several years.

“Social and political science research is essential to complement and strengthen biomedical research in order to identify ways forward in the global pandemic,” Kippax writes in a 2009 paper commissioned by the IAS. All interventions-including biomedical ones-have behavioral and social dimensions, Kippax points out: “Irrespective of whether prevention programs or interventions advocate for the use of condoms, clean needles and syringes, microbicides, pre- or post-exposure prophylaxis, or treatment as prevention-all prevention requires that people change their social practices, changes which cannot be effectively sustained unless they are supported by broader social transformation.”

For those of us who have been working in HIV prevention for years, her remarks resonate. The variety of complex individual circumstances and social contexts in which new and promising prevention efforts must operate require strategic, culturally competent planning to have an impact at the individual and community level. The new biomedical interventions hold greatest promise when introduced as part of combination prevention interventions-which also include behavioral and structural components-that are designed for specific contexts and populations. As we learned with PMTCT and are seeing again in scale-up efforts for voluntary medical male circumcision, a strong clinical evidence base is necessary but not sufficient to ensure adoption by countries and communities. These programs succeed when important groundwork is laid that integrates biomedical findings with behavioral and programmatic research.

Our task now is to build bridges between the social sciences, public health, and biomedicine. The field of HIV prevention has for too long been plagued by an artificial divide between the behavioral and the biomedical. But new discoveries, notably those that support treatment as prevention; new policy frameworks, such as the forthcoming PEPFAR guidance on combination prevention; and new implementation science research agendas being implemented by NIH and other agencies, promise to narrow the gap.

We don’t have to go far to find a road map. The family planning field is notable for its commitment to behavioral and programmatic research that enabled the roll-out of contraceptive technologies. During the decades when reproductive health research was at its height, collaboration between scientists and social scientists was essential for success. Much was learned along the way about how to enhance the acceptability of, access to, and continued use of family planning methods-precisely the objectives that will also make these new prevention technologies successful.

As we celebrate the emergence of powerful new biomedical technologies to prevent HIV transmission, and as programs across the globe rev up to take them to scale, please-let’s not neglect to develop the serious social and programmatic research necessary to make them effective.

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